The Patient Care Coordinator is responsible for overseeing the management and coordination of care for the acute inpatient population. The PCC collaborates with rounding MAPMG Hospital Based Service Physicians, patient/family, nursing, utlization review and other members of the healthcare team to assure continuum of patient care progression for clinical and cost-effective outcomes. The PCC facilitates and coordinates with community providers and ambulatory case managers to assist with the appropriate level and transition of care for a safe discharge and preventing a re-admission.

• Completes an initial face-to-face assessment for every admitted member to identify discharge needs within 24hrs of admission.
• Document in KPHC and communicate the assessment outcomes to determine the appropriate transition plan with MAPMG physician healthcare team and patient/family.
• Active participant in daily Care Without Delay (CWD) rounds reporting on patient progression towards the established discharge plan.
• Review and document discharge plan in accordance with KP discharge planning documentation policies, facility policies, and regulatory requirements.
• Document any updates, care progression and barriers to discharge daily, and as indicated on assigned patients.
• Manage timeliness of care progression with physician and nursing staff to prevent avoidable delays and or days.
• Collaborate with Social Worker to coordinate, long-term care, assisted living, financial assistance, and other services, as required.
• Send referrals/communicate with in-network vendors for coordination of post-acute levels of care such as Home Health, DME, IV infusion, SNF, Sub-Acute and Acute Rehab.
• Timely identification, recording, and escalation of delays in care and barriers to discharge. Provide solutions to correct delays and recognize systemic patterns that require corrective action.
• Assure follow up appointments and referrals to ambulatory case manager for high-risk patient population are scheduled and communicated to patient/family prior to discharge.
• Observe all facility safety policies and procedures (infection control, Members Rights policies, and any regulatory requirements)
• Participate in Quality Assurance duties and implementation of programs to improve care Quality Indicators.
• Maintain professionalism with all duties in an effective and timely manner as directed or assigned by designated supervisor.
• Consistently work cooperatively with patients, patients representatives, facility staff, physicians, consultants, and ancillary service providers.